Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00259223 Renewal 01/22/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(c)The agency's self-assessment completed for this home between 8/10/24 to 11/10/24, did not provide a written summary of corrections made for any of the following regulation items identified as violations: 6400.21b; 6400.46b; 6400.51a6; 6400.51b2; and 6400.51b4.A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year. Staff Person #1: 6 Feb 2025- Hire date was 9 Jul 2024, and Individual Rights training was completed 10 Aug 2024; hence agency in NON-COMPLIANCE with regulations. Staff Person #2: The Self-Inspection for Code violation 6400.151a, the physicals were accidentally read in the reverse order. (Please SEE Supporting Document), hence not in violation. 02/19/2025 Implemented
6400.63(a)At 11:43 AM on 1/23/2025, the hot water temperature at the kitchen sink measured 124.8°F. At 11:52 AM, the hot water temperature at the sink in the vacant bedroom's ensuite bathroom measured 124.3°F.Heat sources, such as hot water pipes, fixed space heaters, hot water heaters, radiators, wood and coal-burning stoves and fireplaces, exceeding 120°F that are accessible to individuals, shall be equipped with protective guards or insulation to prevent individuals from coming in contact with the heat source.Our Maintenance person, sub-contractor, installed water heater regulators to all the sinks and shower areas that were in violation of exceeding 120 degrees Fahrenheit to heat temperatures between 108 to 115 degrees. A Paid Invoice with the completed installation of heat regulators to all the homes was issued on 21 February 2025. In addition, there was a counseling session that was agreed upon with Chief Financial Officer (CFO) and the sub-contractor conducted on 21 February 2025 for the duties of going to each home quarterly throughout the year to ensure that the water heat regulators are working properly with compliant code 6400.63(a). The training/consolation form was signed and dated by the contractor on 21 February 2025. In addition, the Site Operations Managers were given a training/counseling session by the CFO in the steps of overseeing their Direct Support Staff of daily checking the water temperatures. The counseling/training form was signed and dated 24 February 2025. The steps consist of DSS performing daily temperature checks throughout the house. If the water temperature is over 120 degrees, the staff are trained to check the water heater to see if it¿s on the lowest level, report it to their supervisor. Still not in compliance, the supervisor will contact the sub-contractor for assistance to ensure that we become compliant, immediately. 02/21/2025 Implemented
6400.64(a)At 11:19 AM on 1/23/2025, the oven's interior base, sides, and glass door were coated in blackened grease and charred food particles.Clean and sanitary conditions shall be maintained in the home. On 1/23/2025 the oven¿s interior base, sides, and glass door have been cleaned from coated blackened grease and charred food particles that were cleaned with oven degreaser on 1/26/2025. All other ovens in used in the homes were checked for functionality, cleanliness and were in good standing Per 55 Code Chapter 6400.63(a). 02/25/2025 Implemented
6400.66At 11:44 AM on 1/23/2025, the light outside of the sliding glass door leading from the living room to the back porch was inoperable. There is not another source of lighting in this area.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. The Maintenance person (Sub-Contractor) change two new batteries inside the lighting unit outside of the sliding glass door leading from the living room to the back porch. An Invoice was issued by the contractor on 21 February 2025 that showed the work was completed. In addition, there was a counseling session that was agreed upon with Chief Financial Officer (CFO) and the sub-contractor conducted on 21 February 2025 for the duties of going to the Vianna home quarterly throughout the year to ensure that the light fixture is operable outside of the sliding door is working properly with compliant code 6400.66. 02/21/2025 Implemented
6400.80(a)At 11:10 AM on 1/23/2025, the home's outside walkway leading to the front door was covered with several inches of snow. Outside walkways shall be free from ice, snow, obstructions and other hazards. The walkway was cleared on 24 January 2025 by a Direct Support Staff. The Site Operation Managers were given a counseling session to make sure that the duties would be performed by the DSS to clear way the walkways. The signed agreement was signed on 24 February 2025 by all Site Operations Managers. For Major snowstorms over three inches, there was a counseling session given to our land-care sub-contractor to clear the driveways for all of the Homes. The agreement was signed on 24 February 2025. 02/24/2025 Implemented
6400.101At 11:24 AM on 1/23/25, the door between the kitchen and the garage had a deadbolt lock requiring a key on the garage side posing an obstructed egress from the garage without a key. The garage does not have a swing door. [Repeat Violation, 1/25/2024]Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. The Maintenance person (Sub-Contractor) removed the dead bolt that required a key on the garage side posing an obstructed egress from the garage without a key on 3 February 2025. A Paid Invoice with the completed installation of removing the deadbolt lock was issued on 21 February 2025. In addition, there was a counseling session that was agreed upon with Chief Financial Officer (CFO) and the sub-contractor conducted on 21 February 2025 for the duties of going to each home quarterly throughout the year to ensure that there are no deadbolt locks on any doors leading to a garage without a key. The training/consolation form was signed and dated by the contractor on 21 February 2025. 02/24/2025 Implemented
6400.110(a)At 11:36 AM on 1/23/2025, the home's attic did not have an automatic smoke detector. A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. The Maintenance person (Sub-Contractor) installed an operable automatic smoke detector in the home's attic. (Please SEE Picture) on 3 February 2025. An Invoice was issued by the contractor on 21 February 2025 that showed the work was completed. In addition, there was a counseling session that was agreed upon with Chief Financial Officer (CFO) and the sub-contractor conducted on 21 February 2025 for the duties of going to the Woodcliffe home quarterly throughout the year to ensure that the operable automatic smoke detector in the home¿s attic is working properly with compliant code 6400.110(a). The CFO will oversee the plan to maintain compliance with 6400.110(a) by sending out quarterly text messages, to remind the sub-contractor to come out and see that the temperature that the smoke detector in the attic is continuing to work properly in maintaining compliance. The confirmation of completing the work will come in as an Invoice from the contractor. In addition, the Sub-Contractor will check quarterly throughout the year to replace new batteries into the smoke detector. 02/21/2025 Implemented
6400.111(a)At 11:36 AM on 1/23/2025, the home's attic did not include a fire extinguisher with a minimum 2-A rating.There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. The Maintenance person (Sub-Contractor) installed an operable automatic smoke detector in the home's attic. (Please SEE Picture) on 3 February 2025. An Invoice was issued by the contractor on 21 February 2025 that showed the work was completed. In addition, there was a counseling session that was agreed upon with Chief Financial Officer (CFO) and the sub-contractor conducted on 21 February 2025 for the duties of going to the Vianna home quarterly throughout the year to ensure that the Fire extinguisher in the home's attic is in compliance. 02/21/2025 Implemented
6400.112(c)The written fire drill records for the fire drill conducted on 10/4/24 did not include the time. This section was left blank.A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. The written fire drill record for the fire drill conducted on 10/4/2024 has been corrected and the time has been added to the fire drill record on 2/5/2025 and all other fire drills for the home have been reviewed to make sure it was completed in its entirety Per 55 Code Chapter 6400.122(c). 02/25/2025 Implemented
6400.163(d)At 11:19 AM on 1/23/2025, the first aid kit in the home contained two 325mg tablets of Acetaminophen.Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked.On1/23/2025, the first aid kit in the home contained two 325 mg tablets of acetaminophen that was removed from the first aid kit on 1/23/2025 once inspection was completed Per 55 Code Chapter 6400.163(d). Site Operations Manager went through all other homes to ensure there were no other prescription medications and syringes with the exception of epinephrine and epinephrine auto injectors all medications are kept in an area or container that is locked. 02/25/2025 Implemented
SIN-00238462 Renewal 01/23/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.101On 1/24/2024 the door leading to the garage had a dead bolt lock on the outside and there was no exit from the garage.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. The Subcontractor replaced locks on basement door and the door leading to the garage that had turn locks on the exterior of which had no exits to the outside. 01/27/2024 Implemented
6400.141(c)(11)Individual #1's physical examination completed 12/04/2023 did not include the individual's need for bloodwork at recommended intervals. This section of the form was blank.The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. Site Operations Manager will continue to schedule for Individual to complete blood work that is recommended by the Primary Care Physician until lab work is completed. Site Operations Manager will ensure that the PCP complete all sections of the Annual Physical Documentation to reflect that the Individual refused or completed the lab work. 03/08/2024 Implemented
6400.181(e)(6)Individual #1's assessment completed 3/31/2023 states they were unable to complete the individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. Individual #1's individual support plan, last updated 7/21/2023, states s/he would not ingest any cleaning product or poisonous substance if left unattended.The assessment must include the following information: The individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials. Site Operations Manager will review ISP and Assessment to reflect that all information is correct and the same. Site operations Manager will make sure that all changes or new updates are submitted to the SC also to reflect the information in the Individuals ISP. 03/08/2024 Implemented
6400.32(h)On 1/24/2024, Individual #2 had an audio monitor in their bedroom, where the sound from the bedroom is projected to the speaker in the kitchen.An individual has the right to privacy of person and possessions.Site Operations Manager has informed Individuals family member that the audio monitors in individuals room and the living room was not allowed in the home. Site Operations Manager removed the Audio Monitor out of the home. 03/08/2024 Implemented
6400.207(5)(II)On 1/24/2024, Individual #2 had portable bed rails on the side of his/her bed that restrict movement. There was no order from a physician to use these devices.A mechanical restraint, defined as a device that restricts the movement or function of an individual or portion of an individual's body. A mechanical restraint includes a geriatric chair, a bedrail that restricts the movement or function of the individual, handcuffs, anklets, wristlets, camisole, helmet with fasteners, muffs and mitts with fasteners, restraint vest, waist strap, head strap, restraint board, restraining sheet, chest restraint and other similar devices. A mechanical restraint does not include the use of a seat belt during movement or transportation. A mechanical restraint does not include a device prescribed by a health care practitioner for the following use or event: Balance or support to achieve functional body position, if the individual can easily remove the device or if the device is removed by a staff person immediately upon the request or indication by the individual, and if the individual plan includes periodic relief of the device to allow freedom of movement.Site Operations Manager will make sure that individuals have all adaptive equipment needed to stay safe in the home. Site Operation will ensure that there are physicians orders for said restrictive. 03/08/2024 Implemented
SIN-00218773 Renewal 02/07/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The self-assessment for the home was completed 11/19/22. The Certificate of Compliance expires 2/20/23.The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. CDR Investments LLC Certificate of Compliance Effective Date: 10 February 2014. The CFO sent out a memo on 9 February 2023 to the CEO, Sites Operations Manager and Directors that stated, "The Self-Assessment would be conducted between 10 August - 10 November, annually, in order to be in compliant with code 15(a) from the 55 PA Code Chapter 6400. When the time to assess the homes, the CEO will breakdown the categories into sections with dates to complete that will coincide with the compliant date of 10 November. 02/09/2023 Implemented
6400.106The furnace of the home was inspected and cleaned 9/22/21 and then again 11/11/22.Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept. The CFO sent out a memo on 9 February 2023 to his secretary to remind himself and the Sites Operation Manager to schedule maintenance with the Boehmer Heating Company for the Furnaces at the beginning of the new Fiscal Year. 02/09/2023 Implemented
6400.112(f)The home conducted fire drills 1/6/22-12/11/22. The front door of the home was used as the exit route for all drills.Alternate exit routes shall be used during fire drills. The Participant Evacuation Form 24 is the documentation for Participant and Staff Fire Drills to comply with the 6400.112(f) from the 55 PA Code Chapter 6400. The Site Operations Manager will make sure that staff uses all three exits of the home during the Monthly Fire Drills. During the Monthly Fire Drills the Participant Evacuation Form 24 will be completed in its entirety to reflect one of the three exits Front Door, Back Door, and Garage Door. During the year the home will reflect that each exit has been uses four times for the year. 02/13/2023 Implemented
6400.151(a)Program Specialist #1 had a physical examination completed 3/7/20 and then again 3/23/22. Direct Service Worker #2 had a physical examination completed 8/9/19 and then again 9/22/21. A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. Charles Rowe, CFO, created a spreadsheet on 8 February 2023 for the three Sites Operation Managers. The Managers will do a check at the beginning of each month (no later than the 5th day) to see that their staff are in-compliance with the Physical/TB Biennial Dates 02/08/2023 Implemented
6400.151(c)(2)Program Specialist #1 had Tuberculin skin testing by Mantoux method with negative results 3/7/20 and then again 3/23/22. Direct Service Worker #2 had Tuberculin skin testing by Mantoux method with negative results 8/10/19 and then again 9/22/21. The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. Charles Rowe, CFO, created a spreadsheet on 8 February 2023 for the three Sites Operation Managers. The Managers will do a check at the beginning of each month (no later than the 5th day) to see that their staff are compliant with the Physical/TB Biennial Dates. 02/08/2023 Implemented
SIN-00184289 Renewal 03/02/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.63(a)On 3/3/2021 at 12:57PM, the hot water temperature in the sink in the bathroom in the hallway of the home measured 140°FHeat sources, such as hot water pipes, fixed space heaters, hot water heaters, radiators, wood and coal-burning stoves and fireplaces, exceeding 120°F that are accessible to individuals, shall be equipped with protective guards or insulation to prevent individuals from coming in contact with the heat source. RV Gaston¿s handy man Services adjusted the water heater boiler between 115-119°F on 3/9/21. CDR Care has hired RV Gaston¿s handy man services to install hot water regulators on the hallway bathroom sink this will be monitored by Site operations manager daily making sure water levels do not exceed 120 degrees F. The Projected completion date 3/29/21.[As per representative of the agency, on 3/1/31 the hot water temperature was lowered at the hot water heaters. Documentation of the hot water temperature from 3/4/21 to 3/17/21, recorded the water temperatures at the sink and bathtub to be 120°F and below. At least quarterly for 1 year, the CEO or designee shall audit the hot water temperature measuring and recording document to ensure water temperature does not exceed 120°F. Immediately, the CEO or designee shall educate all staff persons responsible for ensuring heat sources and water temperature do not exceed 120°F of their responsibilities to measure, record, report and/or adjust water temperatures and heat sources. Documentation of the trainings shall be kept. (DPOC by AES,HSLS on 3/23/2021)] 03/09/2021 Implemented
6400.77(b)The home's first aid kit did not contain tape. A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. New tape has been purchased to replenish the tape missing from the first aid kit on 3/3/2021. Site Operation Manager will ensure items in first aid kit are present daily by completing CDR form 88 first aid kit inventory checklist. [Immediately, upon hire and at least annually, the CEO or designee shall educate all staff persons on the location, requirements of first aid kits, and the replacement and replenishment procedures to ensure all first aid kits have the required items at all times. Documentation of trainings shall be kept. (DPOC by AES,HSLS on 3/23/31)] 03/03/2021 Implemented
6400.51(b)(1)Direct Service Worker #1's orientation completed 10/30/2020 did not encompass the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.The orientation must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.Direct Service Worker #1 on the training sited was conducted 3/9/21. Training on ISP Specifics will be required for all staff. Training on Everyday Lives: Values in Action will be required for all staff. Agency annual training schedule will be implemented to display training requirements. Site-Operation Managers will provide quarterly training date to schedule and track training dates. [Immediately, upon hire and at least quarterly, the CEO or designee shall audit al staff persons training documentation to ensure all staff persons are trained in required topics during orientation and annually. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 3/23/21)] 03/09/2021 Implemented
6400.51(b)(2)Direct Service Worker #1's orientation completed 10/30/2020 did not encompass the prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§10225.101-10225.5102). The child protective services law (23 PA. C.S. §§6301-6386) the Adult Protective Services Act (35 P.S.§§ 10210.101-10210.704) and applicable protective services regulations.The orientation must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§10225.101-10225.5102). The child protective services law (23 PA. C.S. §§6301-6386) the Adult Protective Services Act (35 P.S.§§ 10210.101-10210.704) and applicable protective services regulations.Direct Service #1 on the training sited was conducted 3/9/21. Training on Neglect, Abuse, and Exploitation. Agency annual training schedule will be implemented to display training requirements. Site-Operation Managers will provide quarterly training date to schedule and track training dates. [Immediately, upon hire and at least quarterly, the CEO or designee shall audit al staff persons training documentation to ensure all staff persons are trained in required topics during orientation and annually. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 3/23/21)] 03/09/2021 Implemented
6400.51(b)(4)Direct Service Worker #1's orientation completed 10/30/2020 did not encompass recognizing and reporting incidents.The orientation must encompass the following areas: recognizing and reporting incidents.Direct Service Worker #1 on the training sited was conducted 3/9/21. Training on Incident (Management) Reporting will be required for all staff. Agency annual training schedule will be implemented to display training requirements. Site-Operation Managers will provide quarterly training date to schedule and track training dates. [Immediately, upon hire and at least quarterly, the CEO or designee shall audit al staff persons training documentation to ensure all staff persons are trained in required topics during orientation and annually. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 3/23/21)] 03/09/2021 Implemented
SIN-00213822 Renewal 02/24/2022 Compliant - Finalized